Maggie McKay (Host): It's very unique for a community hospital to have a full-time board-certified pharmacist. But at St. Joseph Hospital, they do, and they are prescribing excellence. Pharmacy Director Ryan Morgan is here to talk about the impact of board-certified pharmacists.

Welcome to Wellness First, a St. Joseph Hospital podcast, where we hear and learn directly from the experts on all things health and wellness. I'm your host, Maggie McKay. Thank you so much for being here, Ryan.

Ryan Morgan, PharmD: Thank you for having me. It's a pleasure.

Host: So, can you explain the significance of having multiple board-certified pharmacists on staff at St. Joseph Hospital, especially in comparison to other community hospitals?

Ryan Morgan, PharmD: Yes, it's kind of like you mentioned too, it's not that common to have board-certified pharmacists. There's usually like maybe a couple at a community hospital. St. Jo's is unique in the sense that about half our staff is board-certified for pharmacists, which is about eight board-certified pharmacists.

Host: And what qualifications are necessary for pharmacists to become board-certified? And how does this certification benefit patient care?

Ryan Morgan, PharmD: So to become board-certified, a pharmacist needs to have significant experience in the concentration that they're certified in, and do an examination to display that competency in addition to the experience. So, what this really does is promote a very knowledgeable pharmacist in that content area of their specialty.

Host: And how does it benefit patient care?

Ryan Morgan, PharmD: So, that extra knowledge and skills will lead to a pharmacist having more tools in the toolbox, if you will, to make sure that the right medication is being ordered and used in the patients based off of their medical history, current disease state and what options available at the facility.

Host: Ryan, how do board-certified pharmacists contribute to the overall healthcare team at St. Joseph Hospital?

Ryan Morgan, PharmD: Yeah. So, St. Joseph Hospital is very good in that it has multidisciplinary team approach. So, the pharmacist is part of that care team where you'll have the physician, the pharmacist, Nursing, Case Management, you know, the whole team. There's multiple other specialties, and pharmacy will really bring that knowledge and drug specifications. Having board-certified pharmacists gives that extra edge to really optimize care and make sure that the patients are receiving or not receiving medication when appropriate. And if they are, it's a nice quality medication.

Host: Can you share some examples of how board-certified pharmacists have made a difference in patient outcomes or experiences?

Ryan Morgan, PharmD: Yeah, certainly. So, we recently had an experience where we had a board-certified psychiatric pharmacist. And he noticed that our patients in the ED boarding might be able to benefit from receiving changes in medications here. And typically, what happens is these patients boarding in the ED are essentially here until they get a spot at the state psych facility, which sometimes can be weeks up to a month, maybe even more. So, he actually reached out to the emergency department physician and worked together on a case to change a patient's medication regime. And what ended up happening is not only did the patient not need to go to the state psych facility, they actually were able to be discharged sooner than anticipated, because we were able to stabilize the patient here through his skill set.

Host: Wow, that's impressive. So, to maintain their certification, what additional training, if any, or education do board-certified pharmacists undergo?

Ryan Morgan, PharmD: Yeah. So, they have to do extra certifications, so continuing educations, rather, to maintain their certification. So for myself, I know it's a hundred CEs extra every seven years. Some specialties are 150 continuing educations. So, that's the extra study that we put in to prove or to maintain the current knowledge of what the current guidelines are, what medications are out there and available. So, there's that cycle of really educational constraints put on us to make sure that we are keeping up-to-date and knowledgeable within that field. If we fail to do that, then the certification is ruined.

Host: So in what ways do board-certified pharmacists collaborate with other healthcare professionals, like physicians and nurses, to optimize patient care?

Ryan Morgan, PharmD: Like that multidisciplinary team approach I mentioned before, when we go to rounds, we'll often have a section in rounds where it's our turn to speak, if you will, or we might chime in to the provider of the care team to let them know what recommendations we might have. We call them interventions, where we intervene on the therapy to recommend a modification or discontinuation or any kind of educational that we see an opportunity for to provide.

Nursing, we do a lot of helping facilitate medications, a lot of education. That's probably a big one. You'll often see, especially with board-certified pharmacists, really good clinical pharmacists. Often the nurses will just go right to the pharmacist to ask questions instead of the provider because we're easily accessible and, when it comes to the medications, are usually a little more versed at optimizing care with the medications including like which medication to give first if there's multiple, how to give the medication, when to maybe hold that medication or ask the provider for an order to hold or stop the medication, items like that.

Host: Ryan, how does having board-certified pharmacists on staff enhance medication management practices within the hospital?

Ryan Morgan, PharmD: So, it provides a very vast knowledge, you know, that extra experience required and that training and that continuing education really brings in a lot of information to the game to be shared with the team. And then when it comes to medication management, like I mentioned, deciding which medications are appropriate to deploy and at what times to you know, use them or when to not use them, how to store them, when they are no longer good, when they should be discarded, when they should be maybe changed, when there should be dose changes. All of that kind of comes in and it's patient specific, like tailored to each individual on how we will handle that, which is a huge advantage to pharmacy staff.

Host: It's such a responsibility and a crucial job to have. I mean, I think it would be very reassuring to patients knowing all that extra education and you have to maintain your certification. What specific areas of expertise do board-certified pharmacists bring to St. Joseph Hospital that may not be as readily available at other community healthcare settings?

Ryan Morgan, PharmD: The biggest one is psychiatry. So, there are, I believe, five board-certified psychiatric pharmacists in the state of New Hampshire. And I only know of one working in an acute care hospital, which is ours. The other ones, I'm not sure if they're working in that facility, even in the state, let alone acute care. So, that's a huge advantage. In the whole country, there's not many psych pharmacists. We're lucky to have one. Other than that, we have pharmacotherapy specialists. We have critical care pharmacists. I myself am board-certified in critical care. We have sterile compounding pharmacists. We have an oncology board-certified pharmacist, and they really bring a lot of knowledge and skill set to each of those different patient populations.

Host: And how does the presence of board-certified pharmacists contribute to medication safety initiatives at the hospital?

Ryan Morgan, PharmD: So yeah, we can leverage that skill set to help with quality improvement and safety. We actually maintain the medication safety committee at the hospital, where we review medication management practices, determine what medications are being used, if they're appropriate, if they caused harm. And if so, why or how could it have been prevented? Can we educate to change that?

In addition, we can be pulled into maybe non-pharmacy reviews that might kind of allude to pharmacy. For example, if a patient falls, then we'll have a pharmacist review the patient's medications to see what they were on, to see if it was something that may have contributed or not to that fall to determine, you know, what was the true etiology? Is it something that can be preventable? Is it something the patient's going to be continually predisposed to going forward? Does it now warrant a change in therapy, or a change in care plan and items like that?

Host: Can you talk about any specialized services or programs that board-certified pharmacists lead or participate in at St. Joseph Hospital?

Ryan Morgan, PharmD: So, we have quite a few committees. Committees are a big one. That's kind of how we get a lot of stuff done in the hospital. So, we have an Antimicrobial Stewardship Committee, which is how to use antibiotics appropriately, and we have pharmacists on that. We have the Pharmacy and Therapeutics Committee, which is really a committee of pharmacy and providers kind of designing how and when medications will be used collaboratively behind the scenes. And a lot of information is needed to make those decisions. Code Blue committee or Critical Care are kind of related to the ICU, ED, the PACU, the surgical center, and how we respond to codes. And those all will come with their own set of how do we use the medications to our advantage in these settings. For example, Code Blue, we all have crash carts to respond to codes and they're pretty standard, but we might make some tweaks of what quantities we want to have in there, what medications we want to add on, or what we might want to remove from our current crash cart box based on current data to make sure that we're treating to guidelines and treating to the right patient.

Host: And have you seen any unique challenges or opportunities that arise from having several board-certified pharmacists on staff at St. Joseph Hospital?

Ryan Morgan, PharmD: The biggest thing is probably just how unique it is. Having a board-certified pharmacist is great. But when it comes to that multidisciplinary approach, really letting other healthcare professionals like providers know what we can do, what our skill set is, it wasn't that long ago that pharmacists were really not so clinical and more operational. It was really the logistics of delivering medications, and just receiving the order and kind of filling it blindly, "This is what you want, this is what you get." We've really changed to be more clinical. And then, more lately with board-certified pharmacists, we've taken that clinical edge and we've ran with it, and really expanded what we can do with it.

So, for example, we use a board-certified pharmacist in our primary care practice, and he has what's called a collaborative practice agreement. So, he actually sees patients on behalf of providers. And based on his interview with the patient and what the patient might be presenting with or complaining about for signs and symptoms, he'll actually manage the medications himself. So, he has the agreement where he can prescribe medications or discontinue medications, he can order lab work, he can order different types of tests. He can monitor glucose monitoring for patients, so they can do it continually at home, which before was only Endocrinology that could do that. So, it's really opening the door into what pharmacists can do. And then, even in other states, we actually see pharmacists getting provider status. So, that's a big thing we're hoping to get in New Hampshire, because between the board-certified pharmacist and provider status, will be a lot of scope that the pharmacists can work within.

Host: Can you elaborate a little bit on any of the research or quality improvement projects that board-certified pharmacists have been involved in at the hospital?

Ryan Morgan, PharmD: Yeah. Certainly, so we'll do things called Medication Use Evaluations, or MUEs, and we'll kind of bring our clinical knowledge to that. And that will kind of help us kind of target specific medications is really what it is. Are we using this medication correctly? Could it be beneficial? Is there a safer way to use it? Is there a better medication to use instead of that? And one of the examples is there's a medication that's antibiotic, and the way it's dosed is typically by taking lab values. It's pretty inconvenient. You have to take the lab value at a very specific time, like within 30 minutes, for accuracy. And then, based on that lab level, we will dose adjust. So, the issue with that is, for nursing, if they're busy, having that tight time constraint is tough. Phlebotomy, if they're going to do the lab draw, same thing, that tight time schedule is kind of tough. For patients, it could be a dissatisfier. For example, if that lab draw has to be at like 2:00 a.m., that means they have to be woken up at 2:00 a.m. We try to avoid that.

But one of the things that we did was we did an MUE on this medication, and then we compared it to a different way to dose it, where we use like this calculus-based formula to really allow us to predict the blood level at any point in time instead of using that tight, rigid lab monitoring instead, and then use that to dose so the patient satisfaction goes up. An even bigger benefit than patient satisfaction is that is shown to come with a significant reduction in the medication actually causing harm to a patient's kidneys. So, you doing that MUE from the pharmacist, we were able to determine a therapy that would be actually safer and more convenient for patients to receive. And based off of that work, we're heading the direction of bringing that into St. Jo's in the next few months.

Host: So looking to the future, Ryan, how do you envision the role of board-certified pharmacists evolving within the healthcare landscape, especially in community hospitals like St. Joseph?

Ryan Morgan, PharmD: I see them growing. I see the quantity of board-certified pharmacists going up. You know, St. Jo's is on the earlier end of that game. We're doing pretty good with that. I see it expanding like that provider status, if that comes in and marries with the board certification, you know, there's going to be a lot of more services that can be offered by a pharmacy. We already have that collaborative practice agreement, like I alluded to. I see that really taking off or exploring that in other areas of the hospital or the health system rather as well. So, it's really expanding. And the pharmacy is growing and pharmacists' role and scope in the healthcare team is evolving rapidly. And I see board certification being a big, big part of that.

Host: Well, it sounds like St. Joseph is on top of it in this area for sure. So, thank you so much for sharing this useful information. It's been fascinating.

Ryan Morgan, PharmD: Thank you so much for having me. I really appreciate it.

Maggie McKay (Host): Again, that's Ryan Morgan. To learn more, visit us online at stjosephhospital.com. And if you found this podcast helpful, please share it on your social channels and check out our entire podcast library for topics of interest to you. I'm Maggie McKay. Thanks for listening to Wellness First, a podcast from St. Joseph Hospital.